Today's Family Medicine News Highlights
August 29, 2014
GTA hospital security breach
Toronto hospital prepares for ebola
Concussion testing draws mixed reviews
President of New Brunswick Medical Society offers recommendations to improve health care
Premiers Conference in Charlottetown - Premiers call for more federal money for health care
Le vaccin expérimental canadien contre l’Ébola fera l’objet d’essais
Le Journal de Montréal
Nomination du Dr Arruda à la tête de trois agences régionales de la santé publique
ICI Radio Canada
Colombie-Britannique : Allaitement presque forcé?
Secteur de la santé : Les provinces ne reçoivent pas assez du fédéral
Primary Care Quality Improvement – the newsletter of the DFCM QI Program
QI Community Spotlight
This issue's QI Community Spotlight features the excellent work Dr. John Maxted is leading around Significant Event Analysis (SEA) and patient safety in primary care at the Markham Family Medicine Teaching Unit. Read his fascinating piece below.
To SEA or Not to SEE!
My experience with patient safety in primary care suggests that one of the greatest challenges in moving forward is akin to keeping the proverbial ostrich from burying its head in the sand! This is not new to patient safety, no matter what sector of the health system. It has been estimated that we pick up only 20-30% of the safety events that often beg for our reflection in healthcare.
But why primary care? I suggest we may be ignoring safety events because: 1) our primary care systems have not attained the level of maturity that hospital care (secondary and tertiary) systems have reached with their greater supporting structures and organization; and 2) we have struggled to find a suitable way in primary care to analyze what we SEE – or don’t want to SEE!
The latter hypothesis is where the SEA helps us to SEE! We have been trialing Significant Event Analysis (SEA) at the Markham Family Medicine Teaching Unit for almost 2 years and are pleased to report its merits. This does not help us to recognize or identify more primary care safety events, though increasing staff awareness of our analyses may help. But it provides an excellent resource, adapted from the Canadian Patient Safety Institute’s Canadian Incident Analysis Framework (2012), that moves us from simply analyzing what happened and why it happened (quality assurance) to how we could improve our systems of care to prevent it from happening again (quality improvement).
There are 3 factors key to the success of SEA’s in primary care patient safety. First, we have found it absolutely essential to explicitly concentrate on system analysis and avoid human error analysis. That is not to say that provider skills and knowledge don’t play any role in patient safety, as we recognized in our paper on Patient Safety in Primary Care (CPSI, 2010). But by far, most patient safety events are caused by a series of smaller contributions to the main event, as in Reason’s Swiss Cheese Model. Second and related to the first, because healthcare services involve humans, it is extremely important to assure and maintain both patient and provider confidentiality and anonymity in our SEA’s through clearly defined requirements in our analytical process. Third, we acknowledge the extra commitment from leaders and work from staff that even one SEA requires. But we can SEE so much more clearly afterward! Our FHT staff is amazed by the results of each SEA, its promotion of transparency in not shying from significant events and the opportunities to improve our systems of care, big or small. SEAing is so much better than not SEEing!
John M Maxted MD MBA CCFP FCFP
Assistant Professor, DFCM, University of Toronto
Board Chair, Health for All FHT
FHO Lead, Markham Family Medicine Teaching Unit